Benign prostatic hyperplasia ( BPH ), also called enlarged prostate , is an increase in non-cancerous prostate size. Symptoms may include frequent urination, problems starting to urinate, weak flow, inability to urinate, or loss of bladder control. Complications can include urinary tract infections, bladder stones, and chronic kidney problems.
The cause is not clear. Risk factors include family history, obesity, type 2 diabetes, insufficient exercise, and erectile dysfunction. Drugs such as pseudoephedrine, anticholinergics, and calcium channel blockers can worsen the symptoms. The underlying mechanism involves the prostate pressing the urethra thus making it difficult to remove the urine out of the bladder. Diagnosis is usually based on symptoms and examination after exclusion of other possible causes.
Treatment options include lifestyle changes, medications, a number of procedures, and surgery. In those with mild symptoms, weight loss, exercise, and decreased intake of caffeine is recommended. In those with more significant symptoms, drugs may include alpha blockers such as terazosin or 5-reductase inhibitors such as finasteride. Surgical removal of the prostate can be performed on those who do not improve with other measures. Alternative treatments, such as saw palmetto, do not seem to help.
Around 105 million people are affected globally. BPH usually begins after age 40. Half of men age 50 and more affected. After age 80 about 90% of men are affected. Although prostate-specific antigen levels may be elevated in men with BPH, this condition does not increase the risk of prostate cancer.
Video Benign prostatic hyperplasia
Signs and symptoms
BPH is the most common cause of lower urinary tract symptoms (LUTS), which is divided into storage, urination, and symptoms that occur after urination. Symptoms of storage include the need for frequent urination, waking at night to urinate, urgency (an urgent need to undo that can not be delayed), accidental urination, including unintentional nighttime urination, or urgent incontinence (leakage of urine after a sudden need to tight to urinate). Symptoms of urination include urinary hesitation (delay between trying to urinate and flow actually begins), intermittent (not continuous), involuntary interruption of urination, weak urinary flow, trying to empty, emptying sensation is incomplete, and drip terminals (uncontrollable leak after end of urination, also called post-dripbling dribbling). These symptoms may be accompanied by pain in the bladder or pain during urination, called dysuria.
Urinary tract obstruction (BOO) may be caused by BPH. The symptoms are abdominal pain, persistent bladder feelings, frequent urination, acute urinary retention (inability to urinate), pain during urination (dysuria), problems of urination, urine flow, slow start and stop (urinary intermittency), and nocturia.
BPH can be a progressive disease, especially if left untreated. Incomplete discharge results in residual urine or urinary stasis, which may lead to an increased risk of urinary tract infections.
Maps Benign prostatic hyperplasia
Cause
Hormones
Most experts consider androgens (testosterone and related hormones) to play a permissive role in the development of BPH. This means that androgens must be present for BPH to occur, but not necessarily directly causing the condition. This is supported by evidence suggesting that neutered boys do not develop BPH when they age. In an unusual study of 26 eunuchs from the Qing dynasty castle still alive in Beijing in 1960, the prostate could not be felt in 81% of the eunuchs studied. The average time since castration was 54 years (range, 41-65 years). On the other hand, some studies have shown that exogenous testosterone is not associated with a significant increase in the risk of BPH symptoms, so the role of testosterone in prostate and BPH cancers remain unclear. A further randomized controlled trial with more participants is needed to measure the risk of exogenous testosterone.
Dihydrotestosterone (DHT), a testosterone metabolite, is an important mediator of prostate growth. DHT is synthesized in the prostate of the circulating testosterone by the action of a 5-ductuctase enzyme, type 2. DHT can act in autocrine mode in stromal cells or in paracrine mode by diffusing to nearby epithelial cells. In both types of cells, DHT binds to nuclear androgen receptors and signals the transcription of mitogenic growth factors in epithelial cells and stroma. DHT is ten times stronger than testosterone because it dissociates from the androgen receptor more slowly. The importance of DHT in causing nodular hyperplasia is supported by clinical observations in which 5-reductase inhibitors such as finasteride are administered to men with this condition. Treatment with 5-reductase inhibitors significantly reduces the DHT content of the prostate and, in turn, reduces prostate volume and BPH symptoms.
Testosterone increases proliferation of prostate cells, but relatively low serum testosterone levels are found in patients with BPH. One small study has shown that medical castration lowers serum levels and prostate hormones unevenly, has a smaller effect on testosterone levels and dihydrotestosterone in the prostate.
Although there is some evidence that estrogen may play a role in the cause of BPH, this effect appears to be mediated primarily through local conversion of androgens to estrogen in prostate tissue rather than the direct effects of estrogen itself. In the canin in vivo castration study, which significantly reduces androgen levels but leaves unchanged estrogen levels, leading to significant prostate atrophy. Studies looking for correlations between prostate hyperplasia and serum estrogen levels in humans generally do not show.
In 2008, Gat et al. The published evidence that BPH is caused by failure in the spermatic venous drainage system results in an increase in hydrostatic pressure and localized testosterone levels rise more than 100-fold above serum levels. If confirmed, this mechanism explains why serum androgen levels do not seem to correlate with BPH and why exogenous testosterone administration will not make much of a difference.
Diet
Studies show that dietary patterns may affect the development of BPH, but more research is needed to clarify any important relationships. Studies from China show that greater protein intake may be a factor in the development of BPH. Men older than 60 in rural areas have very low clinical BPH levels, while men who live in cities and consume more animal protein have a higher incidence. On the other hand, a study on Japanese-American men in Hawaii found a strong negative relationship with alcohol intake, but a weak positive relationship with beef intake. In a large prospective cohort study in the US (Follow-up Study of Health Professionals), the researchers reported a simple association between BPH (men with strong BPH or BPH confirmed BPH) and total energy and protein, but not fat intake. There is also epidemiological evidence linking BPH with the metabolic syndrome (concomitant obesity, glucose metabolism and diabetes disorders, high triglyceride levels, low-density high cholesterol, and hypertension).
Degeneration
Benign prostatic hyperplasia is an age-related disease. Misrepair-accumulation of aging theory suggests that the development of benign prostate hyperplasia is a consequence of fibrosis and weakening of muscle tissue in the prostate. Muscle tissue is important in the function of the prostate, and provides the power to secrete fluid produced by the prostate gland. However, repeated contractions and widening of myofibers will inevitably cause injury and damage to myofibers. Myofibers have low regeneration potential; Therefore, collagen fibers need to be used to replace damaged myofibers. Such errors make weak muscle tissue function, and the fluid secreted by the gland can not be excreted completely. Then, fluid accumulation in the glands increases muscle tissue resistance during contraction and dilation movements, and more and more myofibers will be damaged and replaced by collagen fibers.
Pathophysiology
As men age, the enzyme aromatase and increase activity of 5-alpha reductase. Aromatase and 5-alpha reductase are responsible for converting androgen hormones to estrogen and dihydrotestosterone, respectively. This androgen hormone metabolism causes decreased testosterone but increases DHT and estrogen levels. Estrogen has a key role in cell growth in the prostate and DHT is anabolic hormone that is much stronger than testosterone that when combined, causing synergies to induce BPH.
Both glandular epithelial cells and stromal cells (including muscle fibers) develop hyperplasia in BPH. Most sources agree that of the two tissues, stromal hyperplasia predominates, but the exact ratio of the two is unclear. : 694
Anatomically, the median and lateral lobes are usually enlarged, due to its extremely high glandular composition. The anterior lobe has little in the way of glandular tissue and is seldom enlarged. (Prostate carcinoma usually occurs in the posterior lobe - the ability to distinguish irregular outlines per rectal examination). Early microscopic signs of BPH usually begin between the ages of 30 and 50 years in PUG, which are posterior to the proximal urethra. : 694 In BPH, the majority of growth occurs in the transition zone (TZ) of the prostate. : 694 In addition to these two classic areas, the peripheral zone (PZ) is also involved at a lower level. : 695 Prostate cancer usually occurs in PZ. However, BPH nodules, usually from TZ are often biopsied also to rule out cancer in TZ. : 695 However, prostate cancer is most common in PZ rather than TZ; thus, chippings taken from PZ are of limited use.
Diagnosis
The clinical diagnosis of BPH is based on a history of LUTS (lower urinary tract symptoms), rectal examination, and the exclusion of other causes of similar signs and symptoms. The degree of LUTS does not have to match the size of the prostate. Enlarged prostate gland on symmetrical and smooth anal examination supports BPH diagnosis. However, if the prostate gland feels asymmetrical, firm, or nodular, this raises concerns about prostate cancer.
Urinalysis is usually performed when LUTS is present and BPH is suspected to evaluate signs of urinary tract infection, urinary glucose (suggestive of diabetes), or protein in urine (suggestive of renal disease). Blood tests including kidney function tests and prostate specific antigen (PSA) are often ordered to evaluate kidney damage and prostate cancer. However, examination of blood PSA levels for prostate cancer screening is controversial and may not necessarily be indicated in any evaluation for BPH. Benign prostatic hyperplasia and prostate cancer are both able to increase blood PSA levels and increased PSA can not distinguish these two conditions well. If the PSA level is examined and high, further investigation is required. Sizes including PSA density, free PSA, rectal examination, and transrectal ultrasonography can help in determining whether the increase in PSA is due to BPH or prostate cancer. Ultrasound examination of the testes, prostate, and kidney is often performed, again to exclude cancer and hydronephrosis.
A validated questionnaire such as the American Association of Urology Symptoms Index (AUA-SI), International Prostate Symptom Score (I-PSS), and recent UWIN scores (urgency, weak flow, incomplete discharge, and nocturia) useful for making a diagnosis of BPH and measuring the severity of symptoms.
Differential diagnosis
Medical condition
The differential diagnosis for LUTS is broad and includes various medical conditions, neurological disorders, and other diseases of the bladder, urethra, and prostate such as bladder cancer, urinary tract infections, urethral stricture, urethral stone (stone), chronic prostatitis, and prostate. cancer. Neurogenic bladder can cause urinary retention and cause symptoms similar to BPH. This can occur as a result of uncoordinated contractions of bladder muscles or disturbances in bladder muscle contraction time and relaxation of the urethral sphincter. Major causes of neurogenic bladder include central nervous system disorders such as Parkinson's disease, multiple sclerosis, and spinal cord injuries and peripheral nervous system disorders such as diabetes mellitus, vitamin B12 deficiency, and alcohol-induced neural damage. Individuals exposed to heart failure often experience waking up at night to urinate because of the fluid redistribution that accumulates in the swollen legs.
Drugs
Certain medications can increase urinary difficulty by increasing bladder outlet resistance by increasing the smooth muscle tone in the prostate or bladder neck and contributing to LUTS. Alpha-adrenergic agonist drugs, such as decongestants with pseudoephedrine, may increase bladder outlet resistance. In contrast, calcium channel blockers and anticholinergic drugs may aggravate urinary retention by promoting bladder muscle relaxation. Diuretic medications such as loop diuretics (eg, furosemide) or thiazides (eg, chlorthalidone) can cause or worsen urinary frequency and wake up at night to urinate.
Management
Lifestyle
Lifestyle changes to address BPH symptoms include physical activity, reduced fluid intake before bedtime, moderate consumption of alcohol and caffeine-containing products and follow prolonged timed schedules. Patients may also try to avoid products and drugs with anticholinergic properties that may aggravate BPH urinary retention symptoms, including antihistamines, decongestants, opioids, and tricyclic antidepressants; However, changes in medications should be made with the input of a medical professional.
Voiding Position
Urinary urinary position may affect urodynamic parameters (urinary flow rate, urination time, and residual volume of post-void). A meta-analysis found no difference between standing and sitting position for healthy men, but that, for older men with lower urinary tract symptoms, urination in a sitting position:
- decreases the volume of post void rest
- increase maximum urinary flow, in proportion to pharmacological intervention
- reduces the discharge time
This urodynamic profile is associated with a lower risk of urological complications, such as cystitis and bladder stones.
Drugs
The two main drug classes for BPH management are alpha blockers and 5? -reductase inhibitor.
Alpha blocker
Selective? 1 -blockers are the most common choice for initial therapy. They include alfuzosin, doxazosin, silodosin, tamsulosin, and terazosin. They have small to moderate benefits. Fifths are just as effective but have slightly different side effect profiles. The alpha blockers relax the smooth muscle in the prostate and neck of the bladder, thereby reducing the blockage of urine flow. Common side effects of alpha blockers include orthostatic hypotension (head fever or dizziness when standing or stretching), ejaculatory changes, erectile dysfunction, headache, nasal congestion, and weakness.
Tamsulosin and silodosin are selective 1-receptor blockers that typically bind to 1A receptors in the prostate in lieu of the 1B receptor in the blood vessels. Less selective? 1 receptor blockers such as terazosin and doxazosin can lower blood pressure. The older, less selective? 1-adrenergic prazosin blocker is not a first-line option for either high blood pressure or prostate hyperplasia; it is an option for patients present with both problems at the same time. Older non-selective alpha blocker drugs such as phenoxybenzamine are not recommended for BPH control. Non-selective alpha blockers such as terazosin and doxazosin may also require a slow dose adjustment as they can lower blood pressure and cause syncope if the response to the drug is too strong.
5? -Reductase inhibitor
The 5? -reductase inhibitor finasteride and dutasteride can also be used in men with BPH. These drugs inhibit enzyme 5? -the captase, which, in turn, inhibits the production of DHT, the hormone responsible for enlarging the prostate. Effects can last longer than alpha blockers, but they persist for years. When used together with alpha blockers, no benefits are reported in short-term trials, but in longer-term studies (3-4 years) there is a greater decrease in the development of BPH into acute urine retention and surgery than with agents alone, especially in patients are more severe symptoms and larger prostates. Other trials have confirmed symptom reduction, within 6 months in a single trial, the effects maintained after withdrawal of the alpha block. Side effects include decreased libido and ejaculation or erectile dysfunction. The 5? -inductase inhibitors are contraindicated in pregnant women due to their teratogenicity due to interference with fetal testosterone metabolism, and as a precaution, pregnant women do not have to deal with crushed or damaged tablets.
More
Antimuskarinik such as tolterodin can also be used, especially in combination with alpha blockers. They act by reducing the effects of acetylcholine on the bladder smooth muscle, thus helping to control overactive bladder symptoms.
Phosphodiesterase-5 inhibitors such as sildenafil citrate show some symptom relief, suggesting a possible common cause with erectile dysfunction. Tadalafil is considered subsequently rejected by NICE in the UK for the treatment of symptoms associated with BPH. In 2011, the US Food and Drug Administration approved tadalafil for treating signs and symptoms of benign prostate hyperplasia, and for the treatment of BPH and erectile dysfunction (ED), when the conditions occurred simultaneously.
Self-catheterization
Intermittent urine catheterization is used to relieve the bladder in people with urinary retention. Self catheterization is an option in BPH when it is difficult or impossible to completely empty the bladder. Urinary tract infections are the most common complication of intermittent catheterization. Some techniques and types of catheters are available, including sterile (disposable) and clean (multiple use) catheters, but, based on current information, none are superior to others in reducing the incidence of urinary tract infections.
Surgery
If ineffective medical treatment one can try office-based therapy or transurethral prostate resection (TURP), surgery may be necessary. Surgical techniques used include the following:
- Open prostatectomy: usually not done at this time, even if the results are very good.
- Transurethral resection of the prostate (TURP): gold standard.
- Transurethral incision of the prostate (TUIP): rarely performed; the technique is similar to TURP but less definitive.
- Vascular (laser) photoelective blur (PVP): general treatment.
Endovascular
The latest alternative to surgical treatment is arterial embolization, endovascular procedures performed in interventional radiology. Through the catheter, the embolic agent is released in the main branch of the prostate artery, to induce a decrease in the size of the prostate gland, thus reducing urinary symptoms.
Alternative medicine
While herbal remedies are commonly used, 2016 reviews find them no better than placebo. Seeing palmetto extract from Serenoa repens, while one of the most commonly used, is no better than placebo in relieving symptoms and reducing prostate size. Other herbal medicines include beta-sitosterol from Hypoxis rooperi (African star grass) and pygeum (extracted from the skin of Prunus africana ), while there is less substantial support for seed efficacy pumpkin ( Cucurbita pepo ) and root nettle ( Urtica dioica ) root. A systematic review of Chinese herbal medicines found that the quality of the study was insufficient to demonstrate any superiority over Western drugs.
Epidemiology
Globally, benign prostatic hyperplasia affects about 210 million men in 2010 (6% of the population).
The prostate gets bigger in most men as they get older. For 46-year-old men, the risk of developing BPH over the next 30 years is 45%. The incidence rate increased from 3 cases per 1,000 male-years at the age of 45-49 years, to 38 cases per 1,000 male-years at the age of 75-79 years. While the prevalence rate of 2.7% for men aged 45-49, increased to 24% at age 80 years.
References
External links
- Extrinsic Compression by Prostate
Source of the article : Wikipedia
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